Discharge Nurse/ Health Coach-Case Manager LPN-RN

VitalCore Health Strategies•Piney Grove Manor, DE

7h•Onsite

About The Position

VitalCore Health Strategies (VCHS) is seeking a Discharge Nurse/Health Coach-Case Manager (LPN or RN) for the Sussex Correctional Institution in Georgetown, DE. This role focuses on preparing inmates for community transition by gathering information, compiling discharge summaries, and providing chronic care patients with a summary of their treatment while in custody. The Health Coach & Case Manager role involves wellness education and connecting patients with community resources, including information on chronic care, healthy living, and social support services like Medicaid and insurance. This position is for individuals passionate about healthcare, not profit-driven.

Requirements

Must have and maintain current licensure as a Licensed Practical Nurse or Registered Nurse in Delaware.
Pre-employment Tuberculin Skin Test and CPR Certification.
Must maintain Full Security Clearance, approved by the Delaware Department of Correction.
Satisfactory background investigation report.

Nice To Haves

Minimum one year of clinical experience (Preferred)

Responsibilities

Identifies chronic care patients and reviews medical, mental health, and substance abuse treatment needs.
Develops written individualized Discharge Summary, including relevant diagnoses, test results, findings, and treatment while in custody of the Department of Correction.
Reviews the risks and needs of each chronic care patient and identifies community-based providers capable of providing ongoing treatment.
Reviews health care records of all chronic care patients in order to develop Discharge Summaries.
Consults with medical, mental health, and substance abuse treatment providers when appropriate.
Consults with Case Managers to ensure patient has the means for connecting with the community-based treatment providers.
In consultation with other treatment staff, maintains database of community-based treatment providers for various specialties.
Respects the dignity and confidentiality of patients.
Attends mandatory staff meetings and trainings.
Performs other duties as assigned.
Identifies high-risk populations and provides wellness education, encouraging patients to lead healthier lives.
Implements curricula developed by Director of Education and Case Management, which focuses on providing patients with information regarding chronic care and healthy living.
Assesses infrastructure issues pertaining to the individual patient and prioritizes patients with the highest risks and the greatest needs.
Provides education on social service infrastructure components, such as accessing Medicaid, Healthcare.gov, and other components relating to the Affordable Care Act.
Conducts post-release follow-up with patients to assess outcomes regarding connectivity, and to continuously evaluate the effectiveness of education and case management.
Provides data to Statewide Performance Improvement team for analysis.
Consults with Discharge Planners as appropriate.